Immigrant Eligibility For Health Coverage Programs

Addressing Concerns Related to Use of Public Benefits Immigrant families may worry that use of government health programsmay affect their ability to change their immigration status “Public charge” is a term used by immigration officials to refer to aperson who is considered primarily dependent on the government forsubsistence Laws and policies around immigrants and public charge have notchanged. Medicaid, CHIP, and Marketplace subsidies have not been considered inscreening for public charge Exception: Medicaid long-term institutional care can be considered as a factor inestablishing public charge Public charge is not a consideration when applying for citizenship?For more information, see NILC’s Tips for Addressing ImmigrantFamilies’ Concerns When Applying for Health Coverage Programs25

Addressing Concerns Related to Privacy Some immigrants fear that completing an application for health coverage— even for a U.S. citizen child — could expose that there are non-citizensin the household Strong privacy rules protect families applying for health insurance,including families whose members have different immigration statusesThe Marketplace, Medicaid, and CHIP laws limit the use of information collectedduring the marketplace application processes: it can only be used to make eligibilitydeterminations and must be protected from unauthorized disclosure for otherpurposes.Citations: 42 U.S.C. § 18081(g)(1); 42 U.S.C. § 1320b-7(a)(5); 42 U.S.C. § 1396a(a)(7)State workers, Marketplace employees and assister groups are required to keepinformation private and secure.Citations: 42 U.S.C. § 18081(g)(2); 42 C.F.R. § 457.1110; 45 C.F.R. § 155.260(a)26

Non-Applicants’ Protections Related to Immigration Status Households may include applicants and non-applicants: Applicants are seeking enrollment and/or eligibility Non-applicants are part of the households of an applicant but are notseeking enrollment or eligibility for themselves Non-applicants do not have to share information about their citizenshipor immigration status But they may have to provide other information such as income27

Requests for Social Security Numbers: ApplicantsMedicaid and CHIPSSNs are generally required of Medicaid applicants Coverage cannot be denied or delayed pending issuance or verification of SSN Medicaid agencies must help individuals apply for an SSN if they are eligible and don’thave one, or if they don’t know their SSNSome applicants do not have to provide Social Security numbers (SSN), including: Newborns in process of obtaining an SSN Persons who have a religious objection Certain lawfully present immigrants who are not eligible for an SSN or can only get anSSN for a non-work purpose such as certain domestic violence survivors, traffickingsurvivors, asylum applicants, and othersMarketplaceOnly applicants who have an SSN are required to provide one.28

Requests for Social Security Numbers: Non-ApplicantsMedicaid and CHIPNon-applicant household members do not have to provide an SSN for Medicaid and CHIP.MarketplaceNon-applicant household members should not be required to provide an SSN unless ALL ofthe following are true: The non-applicant is a tax filer (SSN not required for non-applicant tax dependent) The non-applicant has a SSN The non-applicant filed a federal tax return in the last yearProviding an SSN when available, may increase the likelihood that informationNOTE consumers provide in the application can be verified electronically, which canreduce the amount of paper documentation consumers may have to turn in toprove their circumstances.People who are not eligible for SSNs may use Individual Taxpayer IdentificationNumbers (ITINs) to file taxes, but health insurance affordability programapplications should not request ITINs.29

30Tips For Talking About Immigration Status Do not ask non-applicants to disclose their citizenship or immigration status Use broad questions and share general information about immigrant eligibility tohelp people identify who may want to apply for insurance while providing otherwelcoming messagesFOR EXAMPLE:“We keep your information private and safe. The application asks for someinformation about everyone in your family, but only a family member seekingcoverage for him or herself has to answer questions about immigration orcitizenship.”“The Marketplace provides coverage to citizens and noncitizens who are lawfullypresent. Here’s a list of immigration statuses that are eligible for Marketplacecoverage.” When asking questions about immigration and citizenship status of applicants: Avoid asking if individuals are “undocumented” or “not legally in the U.S.” Instead use words like “eligible immigration status” or “statuses considered eligiblefor the marketplace”?For more information, see NILC’s Tips for Addressing ImmigrantFamilies’ Concerns When Applying for Health Coverage Programs

Example: Jane, Miguel, and Isabella Jane would like to find out healthcoverage options for her family She is not sure if they are eligible forhealth insurance because she andher husband are immigrants She shares that she is worried thatimmigration authorities could useinformation in her application toseparate her familyHow do you start the conversation with Jane?31

Example: Jane, Miguel, and Isabella32Starting the Conversation: Tell her that the conversation is confidential and information she provides in theapplication may only be used for enrollment purposes Explain that the marketplace provides coverage to citizens and many immigrants,and show her the list of immigrants who may be eligible for marketplacecoverage Share that only family members seeking coverage for themselves have to answerquestions about immigration or citizenship status?For a list of statuses eligible for Marketplace coverage, see NILC’s list of“lawfully present” individuals eligible under the ACA

Example: Jane, Miguel, and IsabellaWho is applying for coverage?Show Jane the list of eligible immigration statuses for the marketplace: Who inJane’s household has an eligible immigration status based on that list? Jane came to the U.S. as a child and has Deferred Action for Childhood Arrivals(DACA): She does not have an eligible immigration status and is not eligible forcoverage Her husband, Miguel, has been a lawful permanent resident for four years: He has an eligible immigration status and may be eligible for coverage Isabella was born in the U.S. and is a U.S. citizen: She may be eligible for coverage She was enrolled in CHIP until her first birthday, but she is currentlyuninsured and needs coverage33

Example: Jane, Miguel, and Isabella Jane can apply for coverage on behalf of Miguel and Isabella When filling out the application for coverage, Jane mentions that the family liveswith Miguel’s mother, Gloria She is enrolled in Medicare and does not need health coverage But she is claimed as a dependent by Jane and Miguel Gloria will need to be included in the application as a non-applicant34

Example: Jane, Miguel, and IsabellaWill non-applicants need to provide information on immigration status? Non-applicants should not be asked any questions about immigration status andwill never need to disclose any information about their statusWill non-applicants need to provide an SSN? JANE: Jane has an SSN and is a tax filer Even though she is a non-applicant, she will need to provide her SSN GLORIA: Gloria is not a tax filer and isa non-applicant She does not need to provide anSSN35

Part V:Navigating the Application Process

Eligibility Verification Citizenship and immigrationstatus must be verified Applicants provide SSNsand/or immigrationdocument numbers Those numbers and keyother factors are matchedagainst information ingovernment data files37

38Why Data Matching May Be Unsuccessful Failure to provide SSN or other document numbers, orwrong number provided Name, date of birth and SSN provided on the applicationdo not match what is in SSA or SAVE records: Typos Name changes Data matching limitations: SSA can’t verify citizenship for many citizens whowere born outside of the U.S. SAVE can’t match certain immigrants in “real time”Note: Healthcare.gov has begun automating a second requestfor verification through SAVE!

Notice of a Data-Matching Issue: Eligibility Results On-screen notice of DMI whenapplication is submitted Eligibility notice will detail eligibility and next steps! NEW FOR 20182017 SAMPLE NOTICEFor sample notices, see html39

Tips to Prevent a DMI Make a correct attestation Enter all document numbers thatare requested for applicants Name change: If name on theapplication is not the same as onthe document, use option toprovide name as it appears on thedocument40

41Requested Document NumbersDocument Type:What to List for Document ID:Permanent Resident Card (I-551) Alien registration number Card numberTemporary I-551 stamp (on passport or I-94, I-94A) Alien registration numberMachine Readable Immigrant Visa (with temporary I551 language) Alien registration number Passport number Country of issuanceEmployment Authorization Card (I-766) Arrival/Departure Record (I-94/I-94A) I-94 numberArrival/Departure Record in foreign passport (I-94) Foreign passport Passport number Expiration date Country of issuanceAlien registration numberCard numberExpiration dateCategory codeI-94 numberPassport numberExpiration dateCountry of issuance

42Requested Document NumbersDocument Type:What to List for Document ID:Reentry Permit (I-327) Alien registration numberRefugee Travel Document (I-571) Alien registration numberCertificate of Eligibility for Nonimmigrant StudentStatus (I-20) Student and Exchange VisitorInformation System (SEVIS) IDCertificate of Eligibility for Exchange Visitor Status(DS2019) SEVIS IDNotice of Action (I-797) Alien registration number or an I94 number Description of the type or name ofthe documentOther documents Alien registration number or an I94 number Description of the type or name ofthe document

43Examples of Document TypesPermanent Resident Card (“Green card”, I-551)Alien Registration #(may be referred to as USCIS #)Card NumberTips: If the A# does not have 9 digits, addone or two zeros before the A# sothat you can input nine digits Document/card number may be onthe front or the back of the card andcontains 13 characters: Begins with three letters,followed by ten numbers Some older cards do NOT have cardnumbers Enter “AAA0000000000” as thecard number

Tips to Resolve DMIs Check to make sure the attestation is correct on the application Uploading documents to the marketplace is faster than mail It must be a .pdf, .jpeg, .jpg, .gif, .xml, .png, .tiff, or .bmp It can’t be bigger than 10 MB The file name can’t include a colon, semicolon, asterisk, or any other specialcharacter. Here are a few examples of special characters that can’t be in the filename: / \ : * ? “ If the upload menu does not include the document type the consumer is trying toupload, the consumers can select “other” Citizens likely need two documents One that proves citizenship and one that proves identity Some documents prove citizenship and identity like a U.S. passport44

Documents That Can Be Used to Prove U.S. CitizenshipSubmit any one of the following documents to verify citizenshipU.S. PassportCertificate of CitizenshipState-issued enhanced driver’slicense (EDL)— Currently available in Michigan,New York, Vermont andWashingtonCertificate of NaturalizationDocument from a federally recognized Indian tribe thatincludes the individual’s name, the name of the tribe, andshows membership, enrollment, or affiliation with the tribe— A tribal enrollment card— A Certificate of Degree of Indian Blood— A tribal census document— Documents on tribal letterhead signed by a triballeaderNOTE: If a person does not have one of these documents, they will need two documents to prove citizenship.45

If None of the Previous Documents Are Available:Submit ONE document from EACH column (total of TWO documents)One of the following documents:AND one of the following documents:U.S. public birth certificateConsular Report of Birth Abroad (FS-240, CRBA)Certification of Report of Birth (DS-1350)Certification of Birth Abroad (FS-545)U.S. Citizen Identification Card (I-197 or the prior version I-179)Northern Mariana Card (I-873)Final adoption decree showing the person’s name and U.S.place of birthU.S. Civil Service Employment Record showing employmentbefore June 1, 1976Military record showing a U.S. place of birthU.S. medical record from a clinic, hospital, physician, midwifeor institution showing a U.S. place of birthU.S. life, health or other insurance record showing U.S. place ofbirthReligious record showing U.S. place of birth recorded in theU.S.School record showing the child’s name and U.S. place of birthFederal or State census record showing U.S. citizenship or U.S.place of birthDocumentation of a foreign-born adopted child who receivedautomatic U.S. citizenship (IR3 or IH3)Document must have a photograph or other information,like name, age, race, height, weight, eye color, or addressDriver's license issued by a State or Territory or ID cardissued by the Federal, state, or local governmentSchool identification cardU.S. military card or draft record or Military dependent’sidentification cardU.S. Coast Guard Merchant Mariner cardVoter Registration CardA clinic, doctor, hospital, or school record, includingpreschool or day care records (for children under 19 yearsold)2 documents containing consistent information that provesyour identity, like employer IDs, high school and collegediplomas, marriage certificates, divorce decrees, propertydeeds, or titles46

PTC for Certain Lawfully Present People w/ Low Income For people with income that would potentially qualify them for Medicaid, theMarketplace must verify that applicants are ineligible for Medicaid based on theirimmigration status before determining their eligibility for subsidies If Healthcare.gov can’t electronically verify an individual’s immigration statusthrough SAVE in real time, that person will get an immigration status DMIAS A RESULT:If otherwise eligible for Medicaid based onincome and all other factors:If income is below 100% and not otherwiseeligible for Medicaid (appears to be in thecoverage gap): sent to Medicaid given the opportunity to enroll in aMarketplace plan with no PTC or costsharing reductions (CSR) Asked to submit proof of immigrationstatus47

Process A: Appears Eligible for MedicaidAppears Eligible for Medicaid Based on Income & Other FactorsMarketplace assesses or determines the applicant is eligible for MedicaidCase sent to state Medicaid agency for further eligibility review including verification of immigration statusMedicaid agency notifies applicant that proof is needed including but not limited toimmigration statusIf applicant sends in proof, and is determined ineligible for Medicaid based on status, theMedicaid agency sends applicant denial noticeCase referred back to MarketplaceMarketplace notifies applicant to come back to the Marketplace with instructions on how toget correct eligibility determinationApplicant returns to Marketplace, indicates that has been denied Medicaid and provides otherneeded information to establish eligibilityCorrect eligibility determination for PTC and CSR48

Indicating Ineligibility for Medicaid Based on Status Question individuals will useto indicate they have beendetermined ineligible forMedicaid based on theirimmigration status Exercise caution when helpingsomeone answer thisquestion49

Process B: Treated As If in Medicaid Coverage GapIncome is Below 100% FPL and Not Otherwise Eligible for MedicaidMarketplace determines applicant can enroll in coverage without PTC and notifies applicantthat he may qualify for help paying for coverage but that proof of status is needed to makethat determinationIf applicant sends in proof, case is sent to special unit to determine if eligible under MedicaidrulesIf determined ineligible for Medicaid based on status, Marketplace notifies applicant abouteligibility for subsidies and special enrollment period (as applicable)Applicant returns to Marketplace to select a plan with PTC and CSR (and willbe granted a SEP, as applicable)50

ResourcesNational Immigration Law Center (NILC) Resources: Tips for Addressing Immigrant Families’ Concerns When Applying for Health CoveragePrograms: -concerns-health-coverage-applications/ Know Your Rights: Is it Safe to Apply for Health Insurance or Seek Health th-insurance-and-care-rights/ erechos-seguro-y-cuidado-de-salud/ (Spanish) Trump’s Executive Orders and Immigrants’ Access to Health, Food and Other PublicPrograms, Things to Keep in Mind When Talking with /exec-orders-and-access-to-public-programs/ Health Care Providers and Immigration Enforcement: Know Your Rights, Know YourPatients’ Rights: t/healthcare-provider-and-patientsrights-imm-enf/ Frequently Asked Questions on DACA Termination: aq/ “Lawfully Present” Individuals under the Affordable Care Act: sent/51

ResourcesMarketplace Resources: Assister Guide to Immigration Section of Healthcare.gov: assister-guide-to-immigration-section.PDF Eligible immigration statuses for marketplace -status Immigration Document Types: C

Lawful Permanent Resident (LPR/green card holder) Refugee Asylee Cuban/Haitian Entrant Paroled into the U.S. for at least one year Conditional Entrant Granted Withholding of Deportation or Withholding of Removal Battered Spouse, Child and Parent Trafficking Survivor and his/her Spouse, Child, Sibling or Parent Others: